Edmonton Classification System for Cancer Pain (ECS-CP)

Doreen Oneschuk on behalf of the work completed by my fellow colleagues, notably Drs. R. Fainsinger and C.

NekolaichukCHPCA Banff Learning Institute

June 1, 2014

Canadian Hospice Palliative Care Association Learning Institute

Presenter Name: Dr. Doreen Oneschuk

Relationships with commercial interests:No relationships with commercial interests

Faculty/Presenter Disclosure

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Objectives

• To describe the features of the ECS-CP

• To illustrate how to apply the ECS-CP in clinical settings

• To highlight the benefits and challenges of using this tool in interdisciplinary settings

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Advanced Cancer Pain

• Underdiagnosis and undertreatment1

• Complex pain syndromes often require more intense treatment and more time to achieve stable pain control

• No universally accepted system to predict complexity of cancer pain management

1 Cleeland, JAMA, 1998; 17:1877-82

How can we compare?

• TNM classification for cancer

• Allows a common language for clinicians & researchers

• No similar classification system for cancer pain

• Difficult to compare pain treatment results

Why would we need to classify cancer patients with pain?

• Accurate assessment guides management• Poor assessment handicaps management• Teach basic approach often• More opioids and adjuvants will not solve

everything • Wide variation in clinical and research

results in cancer pain medicine

Characteristics of a Cancer Pain Classification System

• Comprehensive

• Prognostic

• Simple to use (or busy clinicians will never use it )

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Development of the Edmonton Classification System for Cancer Pain (ECS-CP)

ESSESS

rESSrESS

ECS-CPECS-CP

1989 - 1995

2000 - 2005

2005 - present

• Inter-rater reliability (Fainsinger et al, 2005)• Predictive validity (Fainsinger et al, 2005)• Construct validity (Nekolaichuk et al, 2005)• Pain intensity as predictor (Fainsinger et al, 2009)• Predictive validity in international sample (Fainsinger et al, 2010)

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N - Mechanism of Pain

I - Incident Pain

P - Psychological Distress

A - Addictive Behavior

C - Cognitive Function

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N - Mechanism of Pain

I - Incident Pain

P - Psychological Distress

A - Addictive Behavior

C - Cognitive Function

Ne Ii Pp Aa Co

Mechanism of Pain (N)

NoNcNeNx

– No pain– Nociceptive pain– Neuropathic pain– Insufficient information to classify

Incident Pain (I)

IoIiIx

– No incident pain– Incident pain present– Insufficient information to classify

Psychological Distress (P)

PoPpPx

– No psychological distress– Psychological distress present– Insufficient information to classify

DiseaseDisease

Pain Patient

Figure 2. ECS-CP Psychological Distress Indicators

Pain intensityOpioid responsivenessOpioid dosingUse of PRN opioidsPain descriptorsPathophysiologyPain history

Recent diagnosisOther symptomsFunctional statusCo-morbiditiesMental health historySubstance abuse hx

AgeSocial isolationSpiritual disconnectionCoping historyChemical copingFamily issuesPersonality

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Addictive Behaviour (A)

AoAaAx

– No addictive behaviour– Addictive behaviour present– Insufficient information to classify

Addictive Behavior

Addiction is a primary, chronic, neurobiologic disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use compulsive use continued use despite harm craving

Plus Guidelines for use

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Cognitive Function (C)

CoCiCuCx

– Normal cognition– Partial impairment– Total impairment– Insufficient information to classify

Interprofessional Approach to using ECS-CP clinically

• Communication tool

• Trigger for referrals– To palliative care inpatient units– Among disciplines

• Use in context of Interprofessional discussions

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Communication Tool

• Allows team members to ‘speak a common language’

• Assists determining reasons for referral

• Aids in discussions in team meetings regarding approach to patient

• Assists at a Zone program level for program planning and resource allocation– Assists with patient triage and referral to appropriate site – Provides description of complexity of pain by site

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Trigger for referrals

• Triggers for automatic referral to Interprofessional (IP) Team members– Pp – psychological distress present– Aa – addictive behavior present

• Potential referrals to IP team members– Px – psychological distress, insufficient info – Ax – addictive behavior, insufficient info

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Interprofessional Discussions

• Allows team to determine which member(s) would be most appropriate to involve initially– Team conference– Psychosocial-spiritual team meetings– Informal discussions

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Case Example: EP

Case example: EP

• 64 yo former rock-band and blues guitar player with prostate cancer, pain ‘10/10’.– widespread bone mets– recent IM nailing left femur– transferred to us post-op for pain management– Chronic pain syndrome post dx 23– On methadone for years– Hx multiple substance Use Disorders

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EP initial assessment

• Mechanism of pain Ne– Mixed - nociceptive somatic pain left femur and hip

area post-op, possible neuropathic features too

• Incident component Ii– Increased with movement

• Psychological distress Px – insufficient information

• Addictive behaviour Ax– Insufficient information

• Cognition Co

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Ne

Ii

Px

Ax

Co

EP becoming more clear

• Mechanism Nc• Incident component Ii• Psychological distress Pp• Addictive behaviour Aa• Cognition usually still Co, but during

episodes of delirium Ci (twice was Cu)

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Nc

Ii

Pp

Aa

Co

Third PartyAssessmentsThird Party

Assessments

PatientReports

Assessment Measures

Fig 3. Psychological Distress Assessment Framework• ESAS-r (black, reverse)• # BTAs per 24 hours• Daily MEDD• Functional status (PPS)• CAGE• Coping Scale?• Distress measure?• Personality measure?

• Daily pain intensity• Pain ≥ 10/10• Increased pain at

night• “Pain all over”

• When you feel down or worried, does it affect your pain? (MD)

• PRN doses when lonely, upset or withdrawn (RN)

• PRN doses during/after a therapeutic session (ID team)

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EP-progress

First month• Pain 8/10• Average 10 BTA/d• Methadone dose over

300mg/day • Bedbound• Drowsy most of the time,

when awake requesting BT Seroquel/methadone/ maxeran

9 months later• Pain 8/10• Average 4 BTA/d• Methadone 10mg po q8h ATC• Ambulating independently

around unit w walker, off unit in wheelchair

• Participating in Tile tales, playing CD of his music, interacting with Staff +family

• Trip to the Mountains x 3d

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EP-Conclusion

• Discharged (which was a challenge) to Assisted living facility (‘gave up smoking.’)

• 6 months in community, care of dedicated Family Physician with expertise in chronic pain management, occasional Acute care admission

• Readmitted from home for functional decline, increasing leg pain, incontinence

• Imaging ruled out SCC/Cauda equina, most due to generalized weakness. Marked cachexia. Same dose of methadone as at discharge. Pt declined wk to week. Support ++ for pt and sister. Spiritual care involvement. Pt requested Priest be called. Family involved. Pt passed away peacefully (on IV abx though) 6 wks later.

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How ECS-CP helped with management

• Strong incident component to pain and use of breakthrough meds prior to mobilizing, use of RT for bone mets, PT helped maximize mobility

• Recognition of patterns of addictive behaviour and titration to function rather than pain score, ability to gradually wean methadone down to 1/10 of original dose

• Recognition of psychological component with IP team involvement

• Fewer episodes of delirium with streamlining of meds

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30Available at www.palliative.org

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Research Hypothesis

Patients with – less problematic pain features (as classified by the ECS-CP)– lower pain intensity and depression scores – absence of a smoking history

will – require a shorter time to achieve stable pain control– require less complicated analgesic regimens – be more responsive to opioid therapy and – use lower opioid doses

than patients with more complex pain syndromes.

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Strengths• Brief• Clinically relevant • Provides a common language• Generalizable across diverse palliative care

settings• Supported by a series of psychometrically sound

validation studies

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Potential Challenges• Adequate training & use of administration manual

• Interpretation of definitions• Stable pain control• Psychological distress in the context of pain• Addictive behavior excludes remote addictive history and

chronic tobacco use

• Challenges of assessing complex features such as incident pain and psychological distress

• Lack of psychometrically sound measures

Conclusion

• Identify patients with more complex pain syndromes, needing more intense interventions. Assists communication with interdisciplinary team.

• Future role in evaluating, treating and reporting research results in cancer pain assessment and management.

• Internationally recognized cancer pain classification system would enable clinicians to better manage cancer pain & allocate resources.